CMS Pub. 100-08, ch. pim83exhibits, § 7.3

Request Repayment of Overpayments

(Rev. 213, Issued: 06-29-07, Effective: 07-30-07, Implementation: 07-30-07)

DATE:

PROVIDER NAME: INTERMEDIARY NAME:

PROVIDER ADDRESS: INTERMEDIARY ADDRESS:

PROVIDER NUMBER:

OPENING:

Dear XXXXXX:

Thank you for your cooperation during the comprehensive medical review conducted at your

facility on ___________. Based on this review, we have reopened claims in accordance with the

reopening procedures at 42 CFR 405.750 and have determined that you have been overpaid in

the amount of ____________. We hope the following information answers any questions you

may have.

REASON FOR REVIEW

This review was conducted because our analysis of your billing data showed that you may be

billing inappropriately for services. (Include in this paragraph any additional details on why the

provider was selected for the review.)

HOW THE OVERPAYMENT WAS DETERMINED

A randomly selected sample of ________ claims processed from ________ to ________ was

selected for review to determine if the services billed were reasonable and necessary and that all

other requirements for Medicare coverage were met. Medical documentation for the selected

claims was reviewed by our medical review staff.

Based on the medical documentation reviewed for the selected claims, we found that some

services you submitted were not reasonable and necessary, as required by the Medicare statute,

or did not meet other Medicare coverage requirements. Along with our claims payment

determination, we have made limitation on liability decisions for denials of those services subject

to the provisions of §1879 of the Social Security Act (the Act). Those claims for which we

determined that you knew, or should have known, that the services were noncovered have been

included in the results of this review. In addition, we have made decisions as to whether or not

you are without fault for the overpayment under the provisions of §1870 of the Act. Those

claims for which you are not without fault have been included in the results of this review. We

projected our findings from the claims that we reviewed to the universe of claims processed

during the time frame mentioned above.

TOTAL OVERPAYMENTS

(List the aggregate overpayments)

Be advised that this overpayment amount is based on your interim payment rate in effect at the

time the review was done. Further adjustments may be made when your cost report is settled.

GENERAL PROBLEMS IDENTIFIED IN THE REVIEW AND/OR CORRECTIVE ACTIONS

TO BE TAKEN

This review has shown that you are not following published Medicare guidelines and policies in

submitting claims for necessary and reasonable ________ services. (Reference any provider

specific education that occurred regarding these services.) Because of these identified problems,

your future claims for _______ may be subject to prepayment review until you correct your

billing.

WHY YOU ARE RESPONSIBLE

You are responsible for the overpayment if you knew or had reason to know that service(s) were

not reasonable and necessary, and/or you did not follow correct procedures or use care in billing

or receiving payment, and you are found to be not without fault under §1870 of the Act.

A list of the specific claims that have been determined to be fully or partially noncovered, the

specific reasons for denial, identification of denials that fall under §1879 of the Act and those

that do not, the determination of whether you are without fault under §1870 of the Act, an

explanation of why you are responsible for the incorrect payment, and the amount of the

overpayment is attached. (Enclose a list of the specific claims from the sample that have been

found not to be covered. See the example within this exhibit.)

The sampling methodology used in selecting claims for review and the method of overpayment

estimation is attached. (Enclosed an explanation of the sampling methodology.)

WHAT YOU SHOULD DO

Please return the amount of the overpayment to us by (insert date, 15 days from date of

letter). However, you may request an extended repayment schedule in accordance with 42 CFR

401.607(c). Please contact (name of contact person at the FI/RHHI) on (phone number of

contact person) to discuss repayment options for the full amount of the overpayment determined

by the projection of errors found on the ___claim sample.

INTEREST

If you refund the overpayment within 30 days, you will not have to pay any interest charge. If

you do not repay the amount within 30 days, interest will accrue from the date of this letter at the

rate of _____ percent for each full 30-day period that payment is not made on time. Medicare

charges interest on its outstanding Part A debts in accordance with §1815(d) of the Act and 42

CFR 405.378.

RECOUPMENT AND YOUR RIGHT TO SUBMIT A REBUTTAL STATEMENT

As provided in regulations at 42 CFR 401.607(a) and 405.370-375, on (insert date provided in

above paragraph captioned, "What You Should Do"), we will automatically begin to recoup the

overpayment amount against your pending and future claims. If you do not repay the debt within

30 days, we will apply your payments, and amounts we recoup, first to accrued interest and then

to principal. Also, in accordance with the Debt Collection Improvement Act, we may refer your

debt to the Department of Treasury for offset against any monies payable to you by the Federal

Government.

You have the right to submit a rebuttal Statement in writing within fifteen days from the date of

this letter. Your rebuttal Statement should address why the recoupment should not be put into

effect on the date specified above. You may include with this Statement any evidence you

believe is pertinent to your reasons why the recoupment should not be put into effect on the date

specified above. Your rebuttal Statement and evidence should be sent to:

FI Name, Address, Telephone #, and Fax #

Upon receipt of your rebuttal Statement and any supporting evidence, we will consider and

determine within fifteen days whether the facts justify continuation, modification, or termination

of the overpayment recoupment. We will send you a separate written notice of our determination

that will contain the rationale for our determination. However, recoupment will not be delayed

beyond the date Stated in this notice while we review your rebuttal Statement. This is not an

appeal of the overpayment determination, and it will not delay recoupment based on §1893(f)(2)

of the Act. If put into effect, the recoupment will remain in effect until the earliest of the

following: (1) the overpayment and any assessed interest are liquidated; (2) we obtain a

satisfactory agreement from you to liquidate the overpayment; (3) a valid and timely appeal is

received; or (4) on the basis of subsequently acquired evidence, we determine that there is no

overpayment.

If you choose not to submit a rebuttal Statement, the recoupment will automatically go into effect

on (insert same date as provided in paragraph captioned, "What You Should Do "). Whether or

not you submit a rebuttal Statement, our decisions to recoup or delay recouping, to grant or

refuse to grant an extended repayment schedule, and our response to any rebuttal Statement are

not initial determinations as defined in 42 CFR 405.704, and thus, are not appealable

determinations. (See also, 42 CFR 401.625 and 405.375(c).)

YOUR RIGHT TO CHALLENGE OUR DECISIONS

This letter serves as our revised determination of the claims listed in the Attachment. If you

disagree with this determination, you may request a redetermination within 120 days of the date

you receive this letter (unless you can show us otherwise, receipt is presumed to be five (5) days

from the date of this letter). You have the right to raise the same issues under this procedure as

you would have in the context of non-sampling claims determinations under Part A and

overpayment recovery. (See 42 CFR 405.701, et seq.) You may ask for a redetermination of the

denials for which you are determined to be liable under §1879 of the Act or for which the

beneficiary is determined to be liable under §1879 of the Act, but declined, in writing, to

exercise his/her appeal rights, and determinations for which you are found to be not without fault

under §1870 of the Act. You may also challenge the validity of the sample selection and the

validity of the statistical projection of the sample results to the universe. (Refer to the appeals

procedure in your Provider Manual § __________ for further details.)

If you have any questions regarding this matter, please contact _________ at

___________. (Provide correspondence address.)

Thank you in advance for your prompt attention to this matter.

Sincerely,

Enclosures